Editorial: The Endocrine Surgeon and Endocrine Neoplasms
From the earliest days of endocrine surgery, the knowledge, experience, and technical
ability of the endocrine surgeon have been paramount determinants of outcome. The
development of radionuclide imaging, computed tomography (CT) scans, and magnetic
resonance imaging have provided increasingly detailed pictures, and radioimmunoassays and
high performance liquid chomatomography have provided more sophisticated biochemical
measurements. However, the preoperative and intraoperative judgment of the experienced
surgeon continues to be the cornerstone of success.
In recent years, CT scans of the abdomen have identified adrenal pathology that was not
seen before. Fortunately, most of these lesions are "incidentalomas" and do not
require surgical treatment. Judgment and experience have allowed us to establish criteria
of tumor size of 5 cm or greater and/or evidence of endocrine function to identify those
individuals who actually require surgical intervention.
Refinements in parathyroid hormone (PTH) assay allowing the measurement of intact PTH
both preoperatively and intraoperatively provide technical adjuncts to our diagnostic
capabilities. However, careful exploration of the neck remains as the sine qua non of an
excellent outcome.
New scanning agents, such as sestamibi for parathyroids, continue the series of imaging
modalities that are reputed to improve and simplify care of the patient with parathyroid
disease. While perhaps simplifying the operative strategy, these imaging modalities remain
dependent on the knowledge, skills, and technical ability of an endocrine surgeon to turn
images into uncomplicated surgical success.
Pathologists have an expanded inventory of antibodies and markers to identify hormones
in endocrine organs. While this has enhanced our understanding of the diseases, the
success of the intervention depends on the surgeon's recognition that endocrine tumors
differ from other tumors. The fact that survival of differentiated carcinoma of the
thyroid is predicted more by the patient's age than by the pathologic findings or even by
lymph node involvement is unlike our experience with nonendocrine tumors. The fact that
multiple glandular disease in hyperparathyroidism is most closely related to hereditary or
metabolic problems is likewise a phenomenon of endocrine tumors that is not identified
with other neoplasms. Most recently, laparoscopy has allowed a new avenue for approaching
the adrenal gland. While prospective studies show only a small difference between outcomes
with the posterior surgical approach to the adrenal gland vs the laparoscopic approach,
laparoscopy clearly provides a new technology and a new window to the adrenal. But it is
the combination of the expertise of the surgeon and the knowledge of when to use the
technology that results in consistent, high quality results.
In this issue of Cancer Control, a sampling of manuscripts describing unusual
types of endocrine disease is presented. These articles are not intended to minimize the
importance of "bread and butter" endocrine problems, such as papillary carcinoma
of the thyroid or solitary parathyroid adenoma. Rather, they are intended to provide the
"spice" that stimulates a broadened interest in the entire field of endocrine
surgery.
Peter J. Fabri, MD
Department of Surgery
University of South Florida College of Medicine Surgical Service
James A. Haley Veterans' Hospital
Tampa, Fla
Back to Cancer Control Journal Volume 4 Number 1